TL;DR
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A study of Medicaid data from 2016 to 2019 found that patients prescribed opioids or gabapentinoids as initial treatment for acute low back pain had higher subsequent rates of opioid use disorder or overdose than patients who did not start those drugs. Chiropractic and physical therapy as initial treatments were associated with lower rates, but the observational study cannot establish that treatments caused those differences.
A study of nearly 400,000 Medicaid enrollees found that people given opioids or gabapentinoids as first-line treatment for acute low back pain had higher subsequent rates of opioid use disorder or overdose than those who did not start those drugs. The findings, reported by researchers in JAMA Network Open, add to evidence behind guidelines that recommend trying nondrug approaches before prescription painkillers for acute back pain.
Researchers led by Kara E. Rudolph of Columbia University analyzed Medicaid records from 25 states from 2016 to 2019. The study identified 399,500 enrollees with a new acute low back pain diagnosis and no recent record of opioid use. Within a month of diagnosis, 21% received an opioid and 5.8% received gabapentin or a similar drug. About 35% received a nondrug treatment, such as chiropractic care, physical therapy or massage.
Compared with patients who did not start an opioid, those prescribed a dose below 50 milligrams in morphine equivalents for at least seven days had a 105.2% higher likelihood of the study’s combined outcome: opioid use disorder or overdose. The corresponding increase was 146.6% for initial opioid doses above 50 milligrams in morphine equivalents. Starting a gabapentinoid was associated with a 101.6% higher likelihood of that combined outcome.
By comparison, starting chiropractic care was associated with a 32.8% lower risk of the combined outcome, while starting physical therapy was associated with a 31.1% lower risk, each compared with not starting that particular treatment. These are associations from health records, not proof that one treatment caused a higher or lower risk. The study did not report opioid use disorder and overdose separately, so it is unclear which outcome accounted for more cases.
Choosing Initial Back-Pain Treatment
The findings matter because opioids are still prescribed early for acute low back pain despite longstanding recommendations against their use as first-line treatment. In this study, more than one in five enrollees received an opioid within a month of diagnosis. The results underline the potential longer-term risks clinicians and patients may weigh when considering treatment, while also pointing to access to nondrug care as part of the discussion.
The researchers said medication may be considered after weighing potential benefits against longer-term risks. If opioids are prescribed, they said, minimizing dose and duration remains prudent. The data do not show that every patient should receive a particular alternative or that nondrug care will be available, suitable or effective for everyone.
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Why First-Line Prescribing Persists
Guidelines have recommended nondrug approaches before medication for acute low back pain for more than a decade. Yet earlier studies cited in the report found that 12% to 20% of patients with private insurance or Medicaid received opioid prescriptions in 2017-2018. The current analysis likewise found that opioids were the most common of the two drug categories highlighted as initial treatment.
Gabapentinoids, including gabapentin and pregabalin, have sometimes been used as alternatives to opioids. The report notes that evidence for their effectiveness in low back pain is poor. The study’s authors said their results support existing guidance against using powerful prescription painkillers as the first treatment for acute low back pain, rather than establishing a new guideline.
“Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks.”
— Kara E. Rudolph and colleagues
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Limits of the Medicaid Findings
The study used observational insurance records, so it cannot establish that the initial treatment caused later opioid use disorder or overdose. Differences between patients, clinicians and access to care may have influenced both treatment choices and outcomes. The analysis covered Medicaid enrollees in 25 states, a population that may not represent people with other insurance or no coverage.
The researchers combined opioid use disorder and overdose into one outcome, leaving the relative contribution of each unknown. The reported cumulative rates for that combined outcome were 1.4% at seven months and 2.3% at 13 months after diagnosis. Records may also miss nonprescription drugs, medicines paid for out of pocket, or care outside the data. The supplied report’s account of these limitations is incomplete, and it does not provide results that resolve those gaps.
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How Clinicians May Apply the Results
The report adds to the evidence clinicians may use when discussing initial treatment for acute low back pain, but it does not announce a change to practice guidelines. The researchers’ stated message is to consider potential benefits and longer-term risks before using medication, and to limit opioid dose and duration when prescribed.
Further research could help clarify whether the associations hold in other populations, how opioid use disorder and overdose contribute separately to the results, and how access to nondrug therapies affects treatment choices. The study does not specify a follow-up date or a planned next research milestone.
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Key Questions
What did the study find about opioids for acute low back pain?
In Medicaid records, starting an opioid was associated with a higher likelihood of the combined outcome of opioid use disorder or overdose than not starting an opioid. The size of the association differed by initial dose and duration; the study does not prove that opioids caused the outcomes.
What were the findings for gabapentin-like drugs?
Starting a gabapentinoid, a drug class that includes gabapentin, was associated with a 101.6% higher likelihood of the combined opioid use disorder or overdose outcome compared with not starting one. This was an observational association, not evidence of causation.
Did physical therapy or chiropractic care reduce risk?
Starting physical therapy or chiropractic care was associated with lower rates of the combined outcome compared with not starting that type of therapy. The study cannot show that these treatments caused the difference or that they are appropriate for every patient.
Can the results be applied to everyone with acute back pain?
Not directly. The analysis covered Medicaid enrollees in 25 states, and its findings may not apply to other populations. It also relied on health records and combined opioid use disorder with overdose in its main outcome.
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